HomeMy WebLinkAboutTR-9271A Michael J. Domino, PresidentFFOC/-.o�y� Town Hall Annex
John M. Bredemeyer, III, Vice-President =21 .� 54375 Route 25
Glenn Goldsmith y P.O. Box 1179
A Nicholas Krupski �y • �� Southold, NY 11971
Greg Williams ��l , �a° Telephone (631) 765-1892
Fax (631) 765-6641
SOUTHOLD TOWN BOARD OF TRUSTEES
YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES
72 HOURS PRIOR TO COMMENCEMENT OF THE ACTIVITIES CHECKED OFF
BELOW
INSPECTION SCHEDULE
Pre-construction, hay bale line/silt boom/silt curtain
1 st day of construction
Y2 constructed
Project complete, compliance inspection;
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Michael J.Domino,President oF S0Town Hall Annex�O l0
John M.Bredemeyer III,Vice-President 54375 Route 25
P.O.Box 1179
Glenn Goldsmith Southold,New York 11971 ;
A.Nicholas Krupski �pQ Telephone(631) 765-1892
Greg Williams y`,ou Fax(631) 765-6641
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Permit No.: 9271A
Date of Receipt of Application: June 21, 2018
Applicant: Michael & Lisa Kurtz
SCTM#: 1000-119-1-9.1
Project Location: 9905 Nassau Point Road, Cutchogue
Date of Resolutionlissuance: July 18, 2018
Date of Expiration: July 18, 2020
Reviewed by: Board of Trustees
Project Description: To install an 84"x84" hot tub placed on a 6" high, 84" wide
by 84" long concrete slab; and install a 2'x4' storage unit.
Findings: The project meets all the requirements for issuance of an
Administrative Permit set forth in Chapter 275 of the Southold Town Code. The
issuance of an Administrative Permit allows for the operations as indicated on the
project plan prepared by North Fork Pool Care, Inc., received on July 27, 2018
and stamped approved on July 30, 2018.
Special Conditions: The installation of a properly sized drywell for hot tub.
Inspections: Final Inspection.
If the proposed activities do not meet the requirements for issuance of an
Administrative Permit set forth in Chapter 275 of the Southold Town Code, a
Wetland Permit will be required.
This is not a determination from any other agency.
Michael J. Domino, President
Board of Trustees
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Michael J. Domino,President So Town Hall Annex`� Ol0
John M.Bredemeyer III,Vice-President 54375 Route 25
P.O.Box 1179
Charles J. Sanders N Southold,New York 11971
Glenn Goldsmith • �Q Telephone(631) 765-1892
A.Nicholas Krupski lifCOU Fax(631) 765-6641
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BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
TO: VI�,IWEI, 4—sk KvPTZ �o ArO�T�I- 11�2K PDIDL
Please be advised that your application dated
1TVW A( 20d has been reviewed
by this Board at the regular meeting of and your application
has been approved pending the completion of the following items checked off below.
,50WiK6r ikSTAUA-VW of A- PkMT4 ScZ6D
Revised Plans for proposed project %yWeu_Fri ffvT To-b
Pre-Construction Hay Bale Line Inspection Fee ($50.00)
1 s' Day of Construction ($50.00)
,Y2 Constructed ($50.00)
Final Inspection Fee ($50.00)
Dock Fees ($3.00 per sq. ft.)
30-Year Maintenance Agreement(complete original form enclosed and submit
to Board of Trustees Office)
The Permittee is required to provide evidence that the non-turf buffer condition of the
Trustee permit has been recorded with the Suffolk County Clerk's Office as a notice covenant
and deed restriction to the deed of the subject parcel. Such evidence shall be provided within
ninety(90) calendar days of issuance of this permit.
Permit fees are now due. Please make check or money order payable to Town of Southold.
The fee is computed below according to the schedule of rates as set forth in Chapter 275 of the
Southold Town Code.
The following fee must be paid within 90 days or re-application fees will be necessary. You will
receive your permit upon completion of the above.
COMPUTATION OF PERMIT FEES:
I _
TOTAL FEES DUE: $
BY: . Michael J. Domino, President
Board of Trustees
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MAP NOT BEARING THE LAND SURVEYORS EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VAUD TRUE COPY. GUARANTEES INDICATED HEREON SHALL RUN
ONLY TO THE PERSON FOR WHOM TILE SURVEY IS PREPARED AND ON HIS BEHALF TO THE TITLE COMPANY.COV£RNMENTA4 AGENCY AND LENDING INSTUROM
—.ffft `-- ------ LISTED HEREON.AND TO THE ASSTGN£ES OF THE LENDING INSDTUIIM GUARANTEES ARE NOT TRANSFERABLE
1T-1' THE OFFSETS OR DIMENSIONS SHOWN HEREON FROM THE PROPERTY LINES TO THE STRUCTURES ARE FOR A SPECIFIC PURPOSE AND USE THEREFORE THEY ARE
f 11 NOT INTENDED 70 MONUMENT THE PROPERTY LINES OR TO WIDE THE ERECTION OF FENCES ADDInONAL STRUCTURES OR AND OTHER IMPROVEMENTS EASEMENTS
{ Li ® j AND/OR SUBSURFACE STRUCTURES RECORDED OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSICALLY EMDENT ON THE PREMISES AT THE nVE OF SURVEY
I i • JUN 2 1 2®1® I SURVEY OF: LOT 80 & P/0 LOT 81 CERTIFIED TO. MICHAEL KURTZ.
MAP OF.AMENDED MAP o. OF NASSUA POINT LISA CLEFF KURTZ;
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SUFFOLK COUNTY, NEW YORK Professional land Surveying and Design
P-O. Box 153 Aquebogue, New York 11931
�a. PHONE(831)298-1588 FAX(631)296-15BB
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P up P/0 LOT 81 FEMA MAP#36103C0506H
AREA 34,204.70 SQ.FT or 0.79 ACRE,-e_ ELE.RON DATUM ---_--------------__
I'' 1,3 � t\ ,p `� �••%+1 �� UNAUTHORIZED AL TERA DON OR ADDIRON TO THIS SURVEY IS A VIOLA 101 OF SEC ION 7209 OF THE NEW YORK STATE EDUCATION LAW COPIES OF THIS SURVEY
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ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED AND ON HIS BEHALF TO THE TITLE COMPANY, GOVERNMENTAL AGENCY AND LENDING INSTITUTION
LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTITUTION. GUARANTEES ARE NOT TRANSFERABLE
�i 11 THE OFFSETS OR DIMENSIONS SHOWN HEREON FROM ME PROPERTY LINES TO THE STRUCTURES ARE FOR A SPECIFIC PURPOSE AND USE THEREFORE THEY ARE
'1 (t44 rl NOT INTENDED TO MONUMENT THE PROPERTY LINES OR TO GUIDE THE EREC77ON OF FENCES ADDITIONAL STRUCTURES OR AND OTHER IMPROVEMENTS EASEMENTS
JUNL 201♦{8 AND/OR SUBSURFACE STRUCNR£S RECORDED OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSICALLY EVIDENT ON THE PREMISES AT THE TIME OF SURVEY
SURVEY OF LOT 80 & P/0 LOT 81 CERTIFIED TO MICHAEL KURTZ,
MAP OF-AMENDED MAP "A•' OF NASSUA POINT LISA CLEFF KURTZ;
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FILED AUG. 16, 1922 No 156 FIDELITY NATIONAL TITLE INSURANCE COMPANY,
SC;J1i,C;d IUWfI
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TOWN OF SOUTHOLD KENNETH M WOYCHUK LAND SURVEYING, PLLC
SUFFOLK COUNTY, NEW YORK Professional Land Surveying and Design
P.O. Box 153 Aquebogue, New York 11931
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Seating Capacity 5-6 Seating Capacity 6-7
Dimensions 84"x 84"x 38" (214 cm x 214 cm x 97 cm) Dimensions 84"x 84"x 38" (214 cm x 214 cm x 97 cm)
Gallons 305(1,155 L) Gallons 305(1,155 L)
Weight(Dry/Full) 900 lbs(408 kg)/4,555 lbs(2,066 kg) Weight(Dry/Full) 935 lbs(424 kg)/4,775 lbs(2,166 kg)
Pumps 2 Pumps 2
Number of Jets 36 Jets(2 Master Blasters®) Number of Jets 36 Jets(2 Master Blasters®)
Water Features 2 Water Features 1
Filtration EcoPur®Charge Filtration EcoPur®Charge
LED Lighting Orion Light System'" LED Lighting Orion Light System'
Noise Reduction System Standard Noise Reduction System Standard
Premium Options Fusion Air Sound System Premium Options Fusion Air Sound System
Wi-Fi Module Wi-Fi Module
QwetFlo Water Care System" QuietFlo Water Care System'
Mast3rPur-Water Management System Mast3rPur-Water Management System
Afterglow Jet Package Afterglow Jet Package
Dream Lighting Dream Lighting
Vac-formed ABS Pan Bottom Vac-formed ABS Pan Bottom
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Dimensions 78"x 78"x 34" (199 cm x 199 cm x 87 cm)
TWILIGHT SERIES 87.3 EFF E[erjlit Gallons 250(946 L)
Seating Capacity 5 Weight(Dry/Full) 840 lbs(381 kg)/3,850 lbs(1,746 kg)
Dimensions 94"x 84"x 38" (239 cm x 214 cm x 97 cm) Pumps 2- _
Gallons 310(1,173 L) Number of Jets 30 Jets(1 Master Blaster®)
Water Features 2
Weight(Dry/Full) 1,025 lbs(465 kg)/4,535 lbs(2,057 kg) Filtration EcoPur®Charge
Pumps 3 LED Lighting Orion Light System'"
Number of Jets 49 Jets(2 Master Blasters®)
Noise Reduction System Standard
Water Features 3
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Michael J. Domino,Preside SpFFD(/-
O�Q COG Town Hall Annex
John M. Bredemeyer III,Vice-Presutent �� 54375 Route 25
Glenn Goldsmith o '" 1 P.O. Box 1179
c
A.Nicholas Krupski Southold,NY 11971
Greg Williams � p� Telephone(631)765-1892
Fax(631)765-6641
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
,
Date/Time: Completed in field by:
North Fork Pool Care, Inc. on behalf of MICHAEL & LISA KURTZ requests an Administrative Permit
to install an 84"x84" hot tub placed on a 6" high, 84" wide by 84" long concrete slab; and install a 2'x4'
storage unit. Located: 9905 Nassau Point Road, Cutchogue. SCTM# 1000-119-1-9.1
CH. 275-3 - SETBACKS
WETLAND BOUNDARY: Actual Footage or OK=4 Setback Waiver Required
1. Residence: 100 feet
2. Driveway: 50 feet
3. Sanitary Leaching Pool (cesspool): 100 feet
4. Septic Tank: 75 feet
5. Swimming Pool and related structures: 50 feet
6. Landscaping or gardening: 50 feet
7. Placement of C&D material: 100 feet
TOP OF BLUFF:
1. Residence: 100 feet
2. Driveway: 100 feet
3. Sanitary leaching pool (cesspool) 100 feet:
4. Swimming pool and related structures: 100 feet
Public Notic f Hearing Card Posted: Y / N
Ch. 275 Ch. 111 SEQRA Type: 1 II Unlisted Action
Type of Application: Pre-Submission Administrative Amendment Wetland
Coastal Erosion Emergency Violation Non-Jurisdiction
Survey <_ 5 years: Y/N Wetland Line by: C.E.H.A. Line
Additional information/suggested modifications/conditions/need for outside
review/consultant/application completeness/comments/standards:
Ver� dofe 9 1 v tP �At �aoevw +,Jw idf-a axw,/ 611- Lar-,,
gaoj MSV dea.A "5rR �a1J�cQ Q�ria✓I'
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I have read & acknowledged the foregoing Trustees comments:
Agent/Owner:
Present were: J. Bredemeyer M. Domino G. Goldsmith N. Krupski
G. Williams Other
OFFICE LOCATION: ®� S® MAILING ADDRESS:
Town Hall Annex ® P.O. Box 1179
54375 State Route 25 Southold, NY 11971
(cor. Main Rd. &Youngs Ave.)
Southold, NY 11971 Telephone: 631 765-1938
® Fax: 631 765-3136
l�C4UfdT`1,� '
LOCAL WATERFRONT REVITALIZATION PROGRAM
TOWN OF SOUTHOLD
MEMORANDUM
To: Michael Domino, President
Town of Southold Board of Trustees
From: Mark Terry, LWRP Coordinator
Date: July 12, 2018
Re: Local Waterfront Coastal Consistency Review for MICHAEL & LISA KURTZ
SCTM# 1000-119-1-9.1
North Fork Pool Care, Inc. on behalf of MICHAEL & LISA KURTZ requests an Administrative
Permit to install an 84"x84" hot tub placed on a 6" high, 84"wide by 84" long concrete slab; and
install a 2'x4' storage unit. Located: 9905 Nassau Point Road, Cutchogue. SCTM# 1000-119-1-9.1
The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the
Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy
Standards. Based upon the information provided on the LWRP Consistency Assessment Form
submitted to this department, as well as the records available to me, it is my recommendation that
the action is CONSISTENT with the Policy Standards and therefore is CONSISTENT with the
LWRP provided:
1. The plan notes that a "leader" and,dry wells will be used to drain the hot tub. Require
a dry well to be shown on the plans.
2. Clarify the setback distance from the hot tub to the regulated feature.
Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its
written determination regarding the consistency of the proposed action.
Cc: Damon Hagan, Assistant Town Attorney
Michael J. Domino, President � WF04eo�y Town Hall Annex
John M. Bredemeyer, III, Vice-President 54375 Route 25
Glenn Goldsmith CO : P.O. Box 1179
A Nicholas Krupski �y • Southold, NY 11971
Greg Williams �( , �a° Telephone (631) 765-1892
Fax (631) 765-6641
SOUTHOLD TOWN BOARD OF TRUSTEES
RIElc[Euv[2
D ,
TO: SOUTHOLD TOWN BUILDING DEPARTMENT JUN 2 5 2018
RE: VERIFICATION OF BUILDING DEPARTMENT PERMIT REQUIREMENTS
BUILDING DEPT•
SCTM#:
TOWN OF SOUTHOLD
Property Owner Name: Karo
Date Sent to Bldg. Dept:
The Office of the Board of Trustees is forwarding the above referenced application for
verification of the Building Department's permitting requirements stated below:
YES NO
Will the proposed project require a Building Permit?
Will the proposed project require a variance determination
from the Zoning Board of Appeals?
Will any part of this application be considered a Demolition
as described under Town Code?
COMMENTS:
Ai 16
Signatur of evie er Date
t
Michael J.Domino,President OF SOUrTown Hall Annex
John M.Bredemeyer III,Vice-President �� l0 P.O. Route 25
P.O.Box 1179
Glenn Goldsmith Southold,New York 11971
A.Nicholas Krupski 7 • aQ Telephone(631) 765-1892
Greg Williams00UN1`1, Fax(631) 765-6641
�y ��
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
This Section For Office Use Only
Coastal Erosion Permit Application
Wetland Permit Application
Administrative Permit
Amendment/Transfer/Extens on o
Received Application: �
Received Fee: $ 100100 _
Completed Application: �� ,,� ,r �� t'7 '
Incomplete: / �r_ —�
SEQRA Classification: Type I_ Type II Unlisted j
Lead Agency Determination: JUN 2 1 2018
Coordination:(date sent): b°l00
p
� W
LRP Consistency Assessment Form Sent:
CAC Referral Sent: r rif Tmvn
Date of Inspection: 7�«� �- Board of
Receipt of CAC Report:
—/ Technical Review:
—Public Hearing Held:
Resolution:
Legal Name of Property Owner(s): M B CkOd� AJ LI�� KJ I*T_.
Mailing Address: Jy ay I�014 Rd . CU�L-Lnc«e 1,iy 035
Phone Number: a,_4!5 - of - e 0CQ
Suffolk County Tax Map Number: 1000 - I I q - 1 - 9.
Property Location: 990-5 w a-ssy
(If necessary, provide LILCO Pole#, distance to cross streets, and location)
AGENT (If applicable): ��f-�°� G,:::� NL CA>, 'Gjr.
Mailing Address: 9:780 H a l p n✓ i ude' oy 11` 5cz
Phone Number: 3 / ` 4�0114
`,,Board of Trustees Applica , Dn
GENERAL DATA
Land Area (in square feet): t a®J-4 -—7®
Area Zoning: Pe- a of I
Previous use of property: RLSA Q 1ha l
Intended use of property: Real&0�ta i
Covenants and Restrictions on property? Yes No
If"Yes", please provide a copy.
Will this project require a Building Permit as per,Town Code? Yes No
If"Yes", be advised this application will be reviewed by the Building Dept. prior to a Board of Trustee review
and Elevation Plans will be required. 1,
Does this project require a variance from the Zoning Board of Appeals? Yes No
If"Yes", please provide copy of decision.
Will this project require any demolition as per Town Code or as determined by the Building Dept.?
Yes No
Does the structure (s) on property have a valid Certificate of Occupancy?X—Yes No
Prior permits/approvals for site improvements:
Agency Date
XNo prior permits/approvals for site improvements.
Has any permit/approval ever been revoked or suspended by a governmental agency?A—No Yes
If yes,provide explanation: 0 4 K O OL-Jlf-Q6 4' - 1�.,:�IEk
Project Description(use attachments if necessary): CL L) 0 it
r�oct - s o z5Imo& LAA I be. A4
I ® va 51� a v S
,,Board of Trustees Applica ' ;-pn
WETLAND/TRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations: 0
Area of wetlands on lot: 46, DOD.00 square feet
Percent coverage of lot: %
Closest distance between nearest existing structure and upland edge of wetlands: feet
Closest distance between nearest proposed structure and upland edge of wetlands: feet
Does the project involve excavation or filling? X No Yes
If yes,how much material will be excavated? ® cubic yards
How much material will be filled? ® cubic yards
Depth of which material will be removed or deposited: feet
Proposed slope throughout the area of operations: 1,.-b
Manner in which material will be removed or deposited:, Cat•h SI0b
c.,-At be_ �a)jo bAixeJ tO 4�_t Haal dm&
00� k6 Witt b
A� 01due J 0'..JJ //Po
Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by
reason of such proposed operations (use attachments if appropriate):
`4 &6 wA bz, o oz5WW k,� )-P_ct�5s n F
hour� 06- ')S4 �6 eb��d) IKJ4-n CA=e4lowk
o eci � N� ® le
617.20
Appendix B
Short Environmental Assessment Form
Instructions for Completing
Part l -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses
become part of the application for approval or funding,are subject to public review,and may be subject to further verification.
Complete Part 1 based on information currently available. If additional research or investigation would be needed to fully
respond to any item,please answer as thoroughly as possible based on current information.
Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful
to the lead agency;attach additional pages as necessary to supplement any item.
Part l -Project and Sponsor Information
Name of Action or Project:
Kuri�
Project Location(describe,and attach a location map):
9965 Oa550ki P��o� Riad c*k, uc_ �y 0936
Brief Description of Proposed Action:
Name o--fQQApplicant or Sponsor: Telephone: 6 T a-4b f q
d�\ f7 �'c � �� ror • Jp�� E-Mail:
Address:
City/PO: � State: I�ode:e
Ju
1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO YES
administrative rule,or regulation?
If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that
may be affected in the municipality and proceed to Part 2. If no,continue to question 2.
2. Does the proposed action require a permit,approval or funding from any other governmental Agency? NO YES
If Yes,list agency(s)name and permit or approval: ❑
3.a.Total acreage of the site of the proposed action? acres
b.Total acreage to be physically disturbed? acres
c.Total acreage(project site and any contiguous properties)owned
or controlled by the applicant or project sponsor? e acres
4. Check all land uses that occur on,adjoining and near the proposed action.
❑Urban ❑Rural(non-agriculture) ❑Industrial ❑Commercial OResidential(suburban)
❑Forest ❑Agriculture ❑Aquatic ❑Other(specify):
❑Parkland
Page 1 of 4
5
5. is the proposed action, NO YES N/A
a.A permitted use under the zoning regulations? � F] F-1
b.Consistent with the adopted comprehensive plan? E ❑
6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES
landscape? ❑ n
7. Is the site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NO YES
If Yes,identify: 4F r. Zb o'e— >( ❑ X
8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES
X EL
b.Are public transportation service(s)available at or near the site of the proposed action? (7 ❑
c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? J� ❑
9.Does the proposed action meet or exceed the state energy code requirements? NO YES
If the proposed action will exceed requirements,describe design features and technologies: lul
Ai
10. Will the proposed action connect to an existing public/private water supply? NO YES
If No,describe method for providing potable water: ®r-
-�Q�Q�� '�p� -¢(� ❑
11.Will the proposed action connect to existing wastewater utilities? NO YES
If No,describe method for providing wastewater treatment: PO_dt, AA
❑
12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES
Places? ❑
b.Is the proposed action located in an archeological sensitive area? IV] ❑
13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES
wetlands or other waterbodies regulated by a federal,state or local agency? ❑
b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? ❑
If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres:
14.Jdentify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply:
Shoreline El Forest ❑Agricultural/grasslands ❑Early mid-successional
❑ Wetland ❑Urban ❑Suburban
15.Does the site of the proposed action contain any species of animal,or associated habitats,listed NO YES
by the State or Federal government as threatened or endangered? Anpli
❑
16.Is the project site located in the 100ear flood plain? ;NO
YES
OnuWD-0 4o
17.Will the proposed action create storm water discharge,either from point or non-point sources? YES
If Yes, ❑
a.Will storm water discharges flow to adjacent properties? �NO DYES
b.Will storm water discharges be directed to established conveyance systemsrunoff and storm drains)?
If Yes,briefly describe: MNO [—]YES
Page 2 of 4
18.Does the proposed action include construction or other activities that result in the impoundment of NO YES
water or other liquids(e.g.retent. n pon ,waste lagoon,da )?
If Yes,explain pure se and size: 1 Pr r,
tl1 � F-1
19.Has the site of the proposed action or an adjoining property been the location of an active or closed NO YES
solid waste managewent facility?
If Yes,describe: Q j((> al NA ❑
20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES
completed)for hazardous waste?
If Yes,describe: ❑
I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY
KNOWLEDGE -
Applicant/sponsor nam . Date:
Signature:
Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the.following
questions in Part 2 using the information contained in Part 1 and other materials submitted by the project sponsor or
otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my
responses been reasonable considering the scale and context of the proposed action?"
No,or Moderate
small to large
impact impact
may may
occur occur
I. Will the proposed action create a material conflict with an adopted land use plan or zoning ❑
regulations? rX
2. Will the proposed action result in a change in the use or intensity of use of land? (� ❑
3. Will the proposed action impair the character or quality of the existing community? ❑
4. Will the proposed action have an impact on the environmental characteristics that caused the ❑
establishment of a Critical Environmental Area(CEA)?
5. Will the proposed action result in an adverse change in the existing level of traffic or ❑
affect existing infrastructure for mass transit,biking or walkway?
6. Will the proposed action cause an increase in the use of energy and it fails to incorporate j� ❑
reasonably available energy conservation or renewable energy opportunities? f�J
7. Will the proposed action impact existing: �/ ❑
a.public/private water supplies?
b.public/private wastewater treatment utilities? ❑
8. Will the proposed action impair the character or quality of important historic,archaeological,
architectural or aesthetic resources? ❑LJ
9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, Elwaterbodies,groundwater,air quality,flora and fauna)?
Page 3 of 4
No,or Moderate
small to large
impact impact
may may
occur occur
10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage � ❑
problems?
11. Will the proposed action create a hazard to environmental resources or human health?
Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every
question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular
element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3.
Part 3 should,in sufficient detail,identify the impact,including any measures or design elements that have been included by
the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact
may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring,
duration,irreversibility,geographic scope and magnitude. Also consider the potential for short-term,long-term and
cumulative impacts.
F] Check this box if you have determined,based on the information and analysis above,and any supporting documentation,
that the proposed action may result in one or more potentially large or significant adverse impacts and an
environmental impact statement is required.
Check this box if you have determined,based on the information and analysis above,and any supporting documentation,
that the proposed action will not result in any significant adverse environmental impacts.
Town of Southold-Board of Trustees �i(s t�
Name of Lead Agency Dave
Michael J. ®om o n® President
Print or Type Name f Responsible icer in Lead Agency Title of Responsible Officer
Signature of Respon ' le Ofricer in Lead Agency Signature of Preparer(if different from Responsible Officer)
PRINT Page 4 of 4
~Board of Trustees Applicg ,on
AUTHORIZATION
(Where the applicant is not the owner)
1
owners of the property identified as S CTM# 1000-�J��t OD 00 06 3 0 00 in the town of
('�:rc t4yC-g L,- ,New York,hereby authorizes )ime-T tt F0 tr- 1:::�-
OA– V - C to act as my agent and handle all
necessary work involved with the application process for permit(s)from the Southold Town
Board of Trustees for this property.
C;(
X
roperty Owner's glignature Property Owner's Signature
SWORN TO BEFORE ME THIS V1- DAY OF 20_JLl _
,, G, C,
otary Public
JANE C COHEN
Notary Public -State of New York
NO. 01C06333267
Qualified in Suffolk County
My Commission Expires Nov 16,2019
-Board of Trustees Applica�,L`;')n
AFFIDAVIT
kVAi &l VVX-&-S�
fes-T-Z--- BEING DULY SWORN
DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE
DESCRIBED PERMIT(S)AND THAT ALL STATEMENTS CONTAINED HEREIN
ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT
ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION
AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES.
THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE
BOARD OF TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES
AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S),IF
GRANTED. IN COMPLETING THIS APPLICATION,I HEREBY AUTHORIZE THE
TRUSTEES,THEIR AGENT(S) OR REPRESENTATIVES,INCLUDING THE
CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO
INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION,
INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF
TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE
COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL
EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM
OF THE PERMIT.
,c x
Signature of Pro rt- Owner SignJi� EfProperty Owner
SWORN TO BEFORE ME THIS �' DAY OF .20
Notary Public
JANE C COHEN
Notary Public-State of NewD2019
NO. 01 C06333267
Qualified in Suffolk Coun
My Commission Expires Nov 1
X
a 5 .
APPLICANT/AGENUREPRESENTATIVE
TRANSACTIONAL DISCLOSURE FORM
The Town of Southold's Code of Ethics prohibits conflicts of interest on the Rart of town officers and em to ees.The u ose of
this form is to provide inforination which can alert the town of possibI6 conflicts ointerest and allow-it to take whatever action is
necessary to avoid same.
YOUR NAME: I C'�Q l r�Z
(Last name,first name,4iiddle initial,unless you are applying to the name of
someone else or other entity,such as a company.If so,indicate the other
person's or company's name.)
NAME OF APPLICATION: (Check all that apply.)
Tax grievance Building
Variance Trustee
Change of Zone Coastal Erosion
Approval ofplat Mooring
Exemption from plat or official map Planning
Other
(If"Other,name the activity.)
Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship tivith any officer or employee
of the Town of Southold? "Relationship"includes by blood,marriage,or business interest."Business interest"means a business,
including a partnership,in which the town officer or employee has even a partial ownership of(or•employment by)a corporation
in which the town officer or employee owns more than 5%of the shares.
YES NO X-
If you answered'YES",complete the balance of this form and date and sign where indicated.
Name of person employed by the Town of Southold
Title or position of that person
Describe the relationship between yourself(the applicantlagenthepresentative)and the town officer or employee.Either check
the appropriate line A)through D)and/or desc4be in the space provided.
The town officer or empibyee or his or her spouse,sibling,parent,or child is(check all that apply):
A)the owner of greater than 5%of the shares of the corporate stock of the applicant
(when the applicant is a corporation);
B)the legal or beneficial owner of any interest in a non-corporate entity(when the
applicant is not a corporation);
C)an officer,director,partner,or employee of the applicant;or
D)the actual applicant.
DESCRIPTION OF RELATIONSHIP
Submitted this 10 day �� 204
Signature
Print N 1ATZ
Form TS 1
� f
APPLICANT/AGENT/REPRESENTATIVE
TRANSACTIONAL DISCLOSURE,FORM
The Town of Southold's Code of Ethics prohibits conflicts of interest on the Dart of town officers and employees.The purpose of
this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is
necessary to avoid same.
YOUR NAME:
(Last name,first name,griddle initial,unless you are applying in the name of
someone else or other entity,such as a company.If so,indicate the other
person's or company's name,)
NAME OF APPLICATION: (Check all that apply.) r
Tax grievance Building
Variance Trustee
Change of Zone Coastal Erosion
Approval of plat Mooring
Exemption from plat or official map Planning
Other
(If"Other',name the activity.) —
Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee
of the Town of•Southold? "Relationship"includes by blood,rrlarriage,or business interest."Business interest"means a business,
including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation
in which the town officer or employee owns more than 5%of the shares.
YES NO
If you answered"YES",complete the balance of this form and date and sign1where indicated.
Name of person employed by the Town of Southold
Title or position of that person
Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check
the appropriate line A)through D)and/or describe in the space provided.
The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply):
A)the owner of greater than 5%of the shares of the corporate stock of the applicgnt
(when the applicant is a corporation);
B)the legal or beneficial owner of any interest in a non-corporate entity(when the
applicant is not a corporation);
C)an officer,director,partner,or employee of the applicant;or
D)the actual applicant.
DESCRIPTION OF RELATIONSHIP
Submitted thi U dAy of � 20$
Signature
Print Name e
Form TS I f
APPLICANT/AGENT/REPRESENTATIVE
TRANSACTIONAL DISCLOSURE,FORM
The Town of Southold's Code of Ethics prohibits conflicts of interest on the hart of town officers and employees.The purpose of
this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is
necessary to avoid same.
YOUR NAME: ( " � 1"1 u —
(Last name,first name,V ddle initial,unless you are applying in the name of
someone else or other entity,such as a company.If so,indicate the other
person's or company's name.)
NAME OF APPLICATION: (Check all that apply.)
Tax grievance Building
Variance Trustee
Change of Zone Coastal Erosion
Approval of plat Mooring
Exemption from plat or official map Planning
Other
(If"Other",name the activity.)
Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee
of the Town of Southold? "Relationship"includes by blood,marriage,or business interest"Business interest"means a business,
including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation
in which the town officer or employee owns more than 5%of the shares.
YES NO
If you answered"YES",complete the balance of this form and date and sign where indicated.
Name of person employed by the Town of Southold
Title br position of that person
Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check
the appropriate line A)through D)and/or describe in the space provided.
The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply):
A)the owner of greater than 5%of the shares of the corporate stock of the applicant
(when the applicant is a corporation);
B)the legal or beneficial owner of any interest in a non-corporate entity(when the
applicant is not a corporation);
C)an officer,director,partner,or employee of the applicant;or
D)the actual applicant.
DESCRIPTION OF RELATIONSHIP
Submitted this day of JJ-e, 200
Signatures
Print Name r
Form TS I
Town of Southold
LWRP CONSISTENCY ASSESSMENT FORM
A. INSTRUCTIONS
1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for
proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This
assessment is intended to supplement other information used by a Town of Southold agency in
making a determination of consistency. *Except minor exempt actions including Building Permits
and other ministerial permits not located within the Coastal Erosion Hazard Area.
2. Before answering the questions in Section C, the preparer of this form should review the exempt
minor action list, policies and explanations of each policy contained in the Town of Southold Local
Waterfront Revitalization Program. A proposed action will be evaluated as to its significant
beneficial and adverse effects upon the coastal area(which includes all of Southold Town).
3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will
affect the achievement of the LWRP policy standards and conditions contained in the consistency
review law. Thus, each answer must be explained in detail, listing both supporting and non-
supporting facts. If an action cannot be certified as consistent with the LWRP policy standards and
conditions,it shall not be undertaken.
A copy of the LWRP is available in the following places: online at the Town of Southold's
website (southoldtown.northfork.net); the Board of Trustees Office, the Planning Department, all
local libraries and the Town Clerk's office.
B. DESCRIPTION OF SITE AND PROPOSED ACTION
SCTM# - - �
PROJECT NAME Ku r-I--L
The Application has been submitted to (check appropriate response):
Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees
1. Category of Town of Southold agency action(check appropriate response):
(a) Action undertaken directly by Town agency(e.g. capital ❑
construction,planning activity, agency regulation,land transaction) ❑
(b) Financial assistance(e.g. grant, loan, subsidy)
(c) Permit, approval, license,certification: PQ
Nature and extent of action: A ��
�S ��D� D-0 8E '3q x M� cjwo'2�
Attach additional sheets if necessary
Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See
LWRP Section III—Policies Pages 6 through 7 for evaluation criteria
❑ Yes ❑ No V Not Applicable
R-e-SOCK41 Q/ 0, rOA-e 4V- NA AL
L c�J
Attach additional sheets if necessary
NATURAL COAST POLICIES
Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP
Section III—Policies Pages 8 through 16 for evaluation criteria
YN Yes ❑ No ❑ Not Applicable ,/
(�M (�5 ' �er- 0 t'b
Attach additional sheets if necessary
Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III
—Policies Pages 16 through 21 for evaluation criteria
Yes ❑ No 'VNN"Not Applicable te-0j
Attach additional sheets if necessary
Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including
Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III—Policies; Pages 22
through 32 for evaluation criteria.
Yes No Not'* splicable J
Attach additional sheets if necessary
Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies
Pages 32 through 34 for evaluation criteria.
❑ Yes ❑ No[:] Not Applicable
Attach additional sheets if necessary
Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous
substances and wastes. See LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria.
❑ Yes ❑ No ❑ Not Applicable
PUBLIC COAST POLICIES
Policy 9. Provide for public access to,-and recreational use of, coastal waters, public lands, and public
resources of the Town of Southold. See LWRP Section III—Policies; Pages 38 through 46 for evaluation
criteria.
1:1Ye Dn
No❑ Not Applicable
Attach additional sheets if necessary
Location of action: 00-s5ow fil 3 cukAgmx- &Y I(q 35
Site acreage: e
Present land use: 1
Present zoning classification: eesln)e-. tc I
2. If an application for the proposed action has been filed with the Town of Southold agency, the following
information shall be provided:
(a) Name of applicant: t�, rK [;D(
(b) Mailing address: 9-1 DD 1--Pai J PJ
(c) Telephone number: Area Code aq l�t -
(d) Application number,if any: �-
Will the action be directly undertaken,require funding, or approval by a state or federal agency?
Yes 11No� If yes, which state or federal agency?
C. Evaluate the project to the following policies by analyzing how the project will further support or
not support the policies. Provide all proposed Best Management Practices that will further each policy.
Incomplete answers will require that the form be returned for completion.
DEVELOPED COAST POLICY
Policy 1. Foster a pattern of development in the Town of Southold that enhances community character,
preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location, and
minimizes adverse effects of development. See LWRP Section III—Policies; Page 2 for evaluation
criteria.
❑Yes F] No � Not Applicable
®-�- <
Attach additional sheets if necessary
Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See
LWRP Section III—Policies Pages 3 through 6 for evaluation criteria
❑ Yes ❑ No
14 Not Applicable
WORKING COAST POLP`_ _'.s
Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in
suitable locations. See LWRP Section III—Policies; Pages 47 through 56 for evaluation criteria.
Yes ❑ N Not Applicable
Ae V C
s C1 p,-1S
Attach additional sheets if necessary
Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic
Estuary and Town waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria.
❑ Yes ❑ No M Not Applicable `
A-;�E AL (�,d( A Qvim l Q _ ..1M 0 rl)-Je— (Q. .
Attach additional sheets if necessary
Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III —Policies; Pages
62 through 65 for evaluation criteria.
❑ Yes ❑ No 11 N t Applicable
nrn'perllf—sJP
Attach additional sheets if necessary
Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP
Section III—Policies; Pages 65 through 68 for evaluation criteria.
❑ Yes ❑ o X Not Applicable
ajWv u ns u er•
PREPARED BY _ � � - TITLE U. DATEIe